High tibial osteotomy versus unicompartmental knee arthroplasty in advanced medial compartmental knee arthrosis: A comparative study with propensity score matched analysis.

BACKGROUND: Isolated knee medial compartmental osteoarthritis(MOA) can be treated with High Tibial Osteotomy (HTO) or Unicompartmental Knee Arthroplasty (UKA). This study aims to describe and compare outcomes of HTO and UKA in patients with isolated severe MOA. The authors hypothesized that similar outcomes can be achieved. METHODS: Data was collected prospectively of HTOs and UKAs performed between January-2016 and April-2021 by a knee surgeon. Oxford Knee Score (OKS), Knee Society Knee Score (KSKS) and Function Score (KSFS) were collected pre-operatively, six-months and two-years post-surgery. OA severity was graded on pre-operative radiograph. Medial Proximal Tibia Angle (MPTA), Lateral Distal Femoral Angle (LDFA), Joint Line Convergence Angle (JLCA) and Hip-Knee-Ankle Angle (HKAA), were measured on full-length radiograph. 47 HTO and 74 UKA were included. Propensity score matching was performed, accounting for preoperative scores, age, gender and body mass index (BMI), before statistical analysis. Level of significance was set at 0.05. RESULTS: Both groups were similar in age(56.42 vs 58.57, p = 0.067), BMI(29.82 vs 29.09, p = 0.484), gender distribution (p = 0.663) and laterality (p = 0.836). Pre-operatively, both groups were similar in clinical scores and lower limb alignment. On follow-up, both groups achieved similar improvements in clinical scores. However, the HTO group reported poorer extension at 6-months (7.91° vs 4.80°, p = 0.013) and 2-years (5.57° vs 3.24°, p = 0.018). Three cases of hinge fracture and six cases of implant removal occurred in the HTO group. One case of tibial fracture occurred in the UKA group. CONCLUSIONS: In severe MOA, similar outcomes were achieved with HTO and UKA at two years.

Good short-term results following arthroscopic deepening trochleoplasty combined with medial patellofemoral ligament reconstruction: surgical technique and outcomes.

PURPOSE: To report short-term results and clinical outcomes of arthroscopic deepening trochleoplasty combined with medial patellofemoral ligament (MPFL) reconstruction utilizing standard arthroscopic instruments in patients of recurrent patellar dislocation and trochlear dysplasia. METHODS: This is a case series of 13 patients between the ages of 14 and 20 years who presented with recurrent patellar dislocation and severe trochlear dysplasia (Dejour grade D). They were treated surgically using an arthroscopic technique from February 2017 to January 2019 and were followed for 18 months. Patients were assessed preoperatively and postoperatively (at 6, 12, and 18 months) with clinical scores (Tegner Activity Score, Lysholm Knee Score, and Kujala Score). RESULTS: There were 69.2% females, and the mean age was 16.4 â€‹± â€‹2.0 years. There were statistically significant improvements in the mean Lysholm and Kujala scores when comparing pre-operative and post-operative scores at every follow-up landmark (p â€‹< â€‹0.05). Comparing the preoperative and 18-month postoperative scores-the Lysholm score improved from 68.2 â€‹± â€‹10.3 to 98.7 â€‹± â€‹2.1 (p â€‹< â€‹0.001), and the Kujala score improved from 50.3 â€‹± â€‹12.0 to 95.4 â€‹± â€‹4.8 (p â€‹< â€‹0.001). Five patients were able to achieve premorbid Tegner activity levels at 12 months, with an additional 5 patients achieving the same premorbid Tegner activity at the 18-month mark. The remaining 3 patients were able to attain >90% of their activity level at 18 months' follow-up. No complications were observed during the follow-up period. CONCLUSIONS: This proposed arthroscopic deepening trochleoplasty technique combined with MPFL reconstruction has demonstrated excellent and reproducible early clinical outcomes. LEVEL OF EVIDENCE: IV.

Mesenchymal stem cell implantation provides short-term clinical improvement and satisfactory cartilage restoration in patients with knee osteoarthritis but the evidence is limited: a systematic review performed by the early-osteoarthritis group of ESSKA-European knee associates section.

PURPOSE: Implantation of mesenchymal stem cells (MSCs) is a potential cell-based modality for cartilage repair. Currently, its clinical use largely surrounds focal cartilage defect repair and intra-articular injections in knee osteoarthritis. The MSCs' implantation efficacy as a treatment option for osteoarthritis remains contentious. This systematic review aims to evaluate studies that focused on MSCs implantation in patients with knee OA to provide a summary of this treatment option outcomes. METHODS: A systematic search was performed in PubMed (Medline), Scopus, Cinahl, and the Cochrane Library. Original studies investigating outcomes of MSCs implantations in patients with knee OA were included. Data on clinical outcomes using subjective scores, radiological outcomes, and second-look arthroscopy gradings were extracted. RESULTS: Nine studies were included in this review. In all included studies, clinical outcome scores revealed significantly improved functionality and better postoperative pain scores at 2-3 years follow-up. Improved cartilage volume and quality at the lesion site was observed in five studies that included a postoperative magnetic resonance imaging assessment and studies that performed second-look arthroscopy. No major complications or tumorigenesis occurred. Outcomes were consistent in both single MSCs implantation and concurrent HTO with MSCs implantation in cases with excessive varus deformity. CONCLUSION: According to the available literature, MSCs implantation in patients with mild to moderate knee osteoarthritis is safe and provides short-term clinical improvement and satisfactory cartilage restoration, either as a standalone procedure or combined with HTO in cases with axial deformity. However, the evidence is limited due to the high heterogeneity among studies and the insufficient number of studies including a control group and mid-term outcomes. LEVEL OF EVIDENCE: IV.

Patients with varus knee osteoarthritis undergoing high tibial osteotomy exhibit more femoral varus but similar tibial morphology compared to non-arthritic varus knees.

PURPOSE: The aim of this study was to compare alignment parameters between patients undergoing high tibial osteotomy (HTO) for knee osteoarthritis (OA) and non-arthritic controls. METHODS: Pre-operative computed tomography images from 194 patients undergoing HTO for medial knee OA and 118 non-arthritic controls were utilized. All patients had varus knee alignment (mean age: 57 ± 11 years; 45% female). The hip-knee-ankle (HKA) angle, mechanical lateral distal femoral angle (mLDFA), medial proximal tibial angle (MPTA) and non-weight-bearing joint line convergence angle (nwJLCA) were compared between "control group" and "HTO group". Femoral and tibial phenotypes were also assessed and compared between groups. Variables found on univariate analysis to be different between the groups were entered into a binary logistic regression model. RESULTS: The mean age was lower (Δ = 4 ± 6 years, p = 0.024), body mass index (BMI) was higher (Δ = 1.1 ± 2.8 kg/m2, p = 0.032) and there were more females (Δ = 14%, p = 0.020) in the HTO group. The HTO group had more overall varus (7° ± 4.7° vs 4.8° ± 1.3°, p < 0.001). There was a significant difference in the mean mLDFA between the two groups with the HTO group having more femoral varus (88.7 ± 3.2° vs 87.3 ± 1.8°, p < 0.001). MPTA was similar between the groups (p = 0.881). Age was found to be a strong determinant for femoral varus (p = 0.03). CONCLUSION: Patients undergoing HTO for medial knee OA have more femoral varus compared to non-arthritic controls while tibial morphology was similar. This will be an important consideration in pre-operating planning for realignment osteotomy in patients presenting with medial knee OA and warrants further investigation. LEVEL OF EVIDENCE: III, retrospective comparative study.

Arthroscopic procedures could delay the need for a subsequent knee arthroplasty in older patients with end-stage osteoarthritis.

BACKGROUND/OBJECTIVE: Arthroscopic surgery in knee osteoarthritis is controversial with many studies refuting its efficacy in recent literature. This study aims to evaluate the mean duration to knee arthroplasty, and the effect of microfracture on the need for subsequent knee arthroplasty in patients above the age of 55 undergoing arthroscopic procedures for osteoarthritis. METHODS: One hundred and nine consecutive patients with diagnosed osteoarthritis who underwent arthroscopic surgery performed from January 2000 to December 2012 on patients aged 55 years and above by a single surgeon were reviewed retrospectively. Demographic data, age at operation, comorbidities, perioperative details and information of subsequent total knee arthroplasty were collected and analysed. RESULTS: There were 38 males and 71 females in our study group. The group was predominantly Chinese (51.38%), with hypertension and hyperlipidaemia being the most common comorbidities, each affecting 57.8% of our study cohort. All patients had a preoperative radiograph and a magnetic resonance imaging confirming the diagnosis of osteoarthritis associated with meniscal tears. Fifty-eight knees underwent microfracture along with arthroscopic meniscectomy. The mean follow-up duration was 127.5 months (10.5 years, range: 67-212 months). Twenty three patients (20.91%) underwent knee arthroplasties subsequently, with the mean duration to arthroplasty being 65.0 months (5.5 years, range: 7-166 months). The odds ratio of avoiding knee arthroplasty with microfracture was 1.03 (95% CI = 0.410-2.581). CONCLUSION: Arthroscopic procedures could possibly delay the need for subsequent knee arthroplasty for approximately 65 months in older patients with osteoarthritis. However, microfracture does not affect the duration between therapeutic arthroscopy and subsequent arthroplasty. Our long-term retrospective study provides an additional step in the understanding of the impact of arthroscopic procedures and a prospective case-control study would be an ideal follow-up to fully justify the application of arthroscopic procedures to delay knee arthroplasty.

Case Report of a Rare Pipkin Type III Femoral Head Fracture.

INTRODUCTION: Femoral head fractures are rare injury compared to other hip pathologies and often associated with posterior hip dislocation. Such fractures are often fraught with complications even after successful surgical fixation. Pipkin described a classification system for such fractures, dividing them into four types, of which Type III (31C.3) fractures are associated with femoral neck fractures. These fractures are the least common and often associated with the worst outcomes. CASE REPORT: We report a rare case of Pipkin Type III fracture after attempted hip relocation and review literature on this topic. A 35-year-old female sustained a right posterior hip dislocation with femoral head fracture following a fall. After attempts of manipulation and reduction, she sustained an iatrogenic right femoral neck fracture resulting in a Pipkin III femoral head fracture. Open reduction and reduction of fracture achieved through headless compression screw of femoral head and cortical screws of femoral neck. Four months after surgery, the patient under osteonecrosis of the femoral head and subsequently required conversion to a right total hip arthroplasty. CONCLUSION: Femoral head fractures have serious sequelae and should be treated with caution. A high index of suspicion is required; hence, if clinically suspicious, proper imaging is paramount to prevent iatrogenic injury to the femoral neck resulting in subsequent avascular necrosis.